R 418.10901 General information.

Rule 901. (1) All health care practitioners and health care organizations, as defined in these rules, shall submit charges on the proper claim form as specified in this rule. Copies of the claim forms and instructions for completion for each form must be provided separate from these rules in a manual on the agency’s website at https://www.michigan.gov/leo/bureaus-agencies/wdca. Charges must be submitted as follows: (a) A practitioner shall submit charges on the CMS1500 claim form. (b) A doctor of dentistry shall submit charges on a standard dental claim form approved by the American Dental Association. (c) A pharmacy, other than an inpatient hospital, shall submit charges on an invoice or an NCPDP workers compensation/property & casualty universal claim form. (d) A hospital-owned occupational or industrial clinic, or office practice shall submit charges on the CMS 1500 claim form. (e) A hospital billing for a practitioner service shall submit charges on a CMS 1500 claim form. (f) Ancillary service charges must be submitted on the CMS 1500 claim form for durable medical equipment and supplies, L-code procedures, ambulance, vision, and hearing services. Charges for home health services must be submitted on the UB-04 claim form. (g) A shoe supplier or wig supplier shall submit charges on an invoice. (2) A provider shall submit all bills to the carrier within 1 year after the date of service for consideration of payment, except in cases of litigation or subrogation. (3) A properly submitted bill must include all the following appropriate documentation: (a) A copy of the medical report for the initial visit. (b) An updated progress report if treatment exceeds 60 days. (c) A copy of the initial evaluation and a progress report every 30 days of physical treatment, physical or occupational therapy, or manipulation services. (d) A copy of the operative report or office report if billing surgical procedure codes 10004-69990. (e) A copy of the anesthesia record if billing anesthesia codes 00100 to 01999. (f) A copy of the radiology report if submitting a bill for a radiology service accompanied by modifier -26. The carrier shall only reimburse the radiologist for the written report, or professional component, on receipt of a bill for the radiology procedure. (g) A report describing the service if submitting a bill for a by report procedure. (h) A copy of the medical report if a modifier is applied to a procedure code to explain unusual billing circumstances. (4) A health care professional billing for telemedicine services shall utilize procedure codes 97161 to 97168, or those listed in Appendix P of the CPT® codebook, as adopted by reference in R 418.10107, excluding CPT® codes 99242 to 99245 and 99252 to 99255. The provider shall append modifier -95 to the procedure code to indicate synchronous telemedicine services rendered via a real-time interactive audio and video telecommunications system with place of service code -02 or -10. All other applicable modifiers must be appended in addition to modifier -95.